F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on interview and record review, the facility failed to ensure medications were administered per
current standards of practice for 1 (R1) of 3 residents reviewed for medication administration in the sample
of 3.
Findings Include:
On 4/12/24 at 8:50 AM, V2 (Director of Nursing) stated she cannot recall the specific date, but does believe
it was in the early afternoon, she was notified by V4 (Certified Nurse Assistant, CNA) that she had found a
cup of medications in R1's room. V2 stated she spoke with V3 (Registered Nurse, RN) who was R1's nurse
that day and educated her that medications could not be left at the resident's bedside, unless that resident
had been assessed for self-administration of medication. V2 stated there were no ill outcomes or incidents
as a result of the medications being left that required the State Agency notification. V2 stated that R1 has
not been screened for self-administration of medicine, but is cognitively intact.
On 4/12/24 at 9:28 AM, V3 (Registered Nurse) stated there was an occurrence a few weeks ago in which
R1 did not take his medications at the time they were provided by herself and were found by V4 (CNA) at
his bedside. V3 stated R1 is not confused and always takes his medications with no concerns. V3 stated
she had prepared R1's medications and given them to him to take, which he said he was going to, so she
moved onto the next person. V3 stated a short time later, V4 had gone to R1's room as the residents were
getting ready to go outside to smoke and saw the cup of medications. V3 stated she never saw the cup of
medications again, so assumes V4 gave him the meds to take. V3 stated she believes it was that same day,
V2 told her not to be leaving medications at the bedside and be sure the resident took the medications in
front of her. V3 stated that is not her normal practice and will ensure she observes resident's take their
medications.
On 4/12/24 at 9:36 AM, V4 (CNA) stated she cannot recall the exact date, but within the last few weeks
there was a time during the morning that she had gone to R1's room and noticed he had left his cup of
medications on his bedside table. V4 stated R1 was in the dining room, so she took the meds to R1 and just
set them down beside him. V4 stated R1 made a comment something to the effect of oops, I forgot those
and started to take the meds. V4 stated that she is a medication technician at her other job, so didn't really
think much about taking him the cup of meds she found. V4 confirms she is not a licensed nurse. V4 stated
R1 is cognitively intact.
On 4/12/24 at 9:15 AM, V1 (Administrator) stated her expectation is that licensed nurses observe residents
take their medications and do not leave them at the bedside. V1 stated that residents are screened for
self-administration of medications in some situations, but verified R1 was not. V1 stated
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
146096
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146096
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Haven of Ridgeview
413 Ridge Lane
Oblong, IL 62449
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
there was no incident or ill effects resulting from R1's medications being left at the bedside.
Level of Harm - Minimal harm
or potential for actual harm
R1's admission Record documented an original admit date to the facility as 6/5/22. Diagnoses listed on this
same document include but are not limited to : Hemiplegia and Hemiparesis following Cerebral Infarction,
Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypertension, Hyperlipidemia, etc .
Residents Affected - Few
Review of the facility policy titled Subject: Medication Administration Policy/Procedure with a revision date
of 9/27/22 documented, Medications will be administered safely to residents within the facility by licensed
nurses at specified time/timeframe, following the recommended administration method and will be
documented as required .It is the responsibility of all licensed nursing staff to safely administer medications
to residents. The same policy goes on to stated, 9. Ensure medication has been swallowed before leaving.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146096
If continuation sheet
Page 2 of 2
